IPhysical
Therapist. PhD in Health Sciences, Graduate Program in Health Sciences, Federal
University of Rio Grande do Norte. Professor at the Federal University of Rio
Grande do Norte. Natal, RN, Brazil. facnat@yahoo.comIIMS in Health Sciences, Graduate Program in Health Sciences, Federal
University of Rio Grande do Norte. Physical Therapist at the Adult Rehabilitation
Center. Natal, RN, Brazil. di_lidice@yahoo.com.brIIIPhysical Therapist. PhD in Education, Graduate Program in Education,
Federal University of Rio Grande do Norte. Professor, Federal University of
Rio Grande do Norte. Natal, RN, Brazil. vera.mrocha@ufrgs.br

The objective of
this study was to have a multidisciplinary team investigate the neurological
state and cognitive performance of patients after a stroke, through a cross-sectional
study with 45 patients in rehabilitation after having an acute stroke. The data
collection instruments used were an assessment sheet, the Mini Mental-MEEM,
and the National International Health Stroke Scale-NIHSS. The sample consisted
mostly of women (55.6%), Ischemic Stroke (86.7%), right hemisphere of the brain
(60%) and Educated (68.8%). The mean MEEM for educated and illiterate patients
was 19.3 ± 5.0 and 15.92 ± 3.7, respectively. The overall mean of
the neurological state was 13.0±4.8. A significant difference was found
between the cognitive means of patients in terms of education (p value = 0.017),
and there was a significant relationship between the neurological state and
cognitive performance (r = -0.44 p value = 0.002). It appears to be a direct
relationship between the neurological state and cognition performance of patients
after an acute stroke, which evinces the need for greater attention to the cognitive
issue involved early in rehabilitation.

Cerebrovascular
Accident (CVA) is defined by the World Health Organization (WHO) as an acute
neurological dysfunction of vascular origin followed by the sudden or rapid
occurrence of signs and symptoms related to compromised focal areas in the brain(1).

The incidence of
CVA has grown due to increased life expectancy, causing changes in the population's
lifestyle(2). CVA is the cause of 9% of deaths around the world,
ranking second after ischemic heart diseases(3).

The proportion
of deaths from CVA is 10-12% in Western countries, while 12% of these deaths
occur in people younger than 65 years old(3). In Brazil, the distribution
of deaths caused by diseases in the circulatory system have increased in significance
among young adults older than 20 years of age and has become the main cause
of death among those in the 40 years old age range, and predominating in the
subsequent age groups(4-5).

CVA is a common
disease having a great impact on world public health because it is the main
cause of neurological impairment and important motor and cognitive dysfunctions(2).
Those surviving a CVA generally face residual impairment such as paralysis of
muscles, stiffness of the affected body parts, loss of joint mobility, diffuse
pain, memory problems, difficulties in oral and written communication, and sensory
disabilities(2,4).

The growth of the
elderly population has increased the risk for the onset of cognitive impairment
since the risk for CVA occurrence also increases(6). Cognitive dysfunctions
are the main causes of impairment in people older than 65 years of age in industrialized
countries. Taking into account that Brazil is considered a developing country
whose classification for elderly individuals includes those around 60 years
of age, such information is even more relevant(1,6).

Reports in the
literature indicate that 5% to 10% of the elderly population presents some cognitive
decline. Since CVA is one of the main causes of this type of impairment, the
incidence of cognitive disorders in the population surviving a CVA varies from
12% to 56%(6-7). CVA can be considered the main cause of cognitive
impairment in elderly individuals, affecting about 50% of patients, both in
the acute and chronic phases(7-8).

Cognitive impairment
is very common after a CVA and can affect attention, memory and the association
of these two skills. Such a fact reduces the organization of thoughts, leading
to a disorganized language process, including problems related to speech and
the sequential production of words, compromising one's ability to understand
written and spoken information(9).

Individuals with
sequelae resulting from a CVA frequently need to take part in a rehabilitation
program. Rehabilitation is a set of actions aimed to reestablish and maintain
one's physical functions; educate the patient and family; and reinsert the patient
into the family's and social circle(1,5). The ability of patients
to succeed in rehabilitation depends on their motivation, social-family support,
and, most importantly, their cognitive condition(10).

The presence of
cognitive disorders is an important predictor of recovery, directly affecting
the patients' rehabilitation and recovery process(11). Many studies
suggest that a patient's cognitive state can influence the results of treatment,
given the fact that the techniques used in the process require some cognitive
skills such as the evocation and execution of instructions(10).

These patients
are required to learn new skills to perform exercises and recall instructions
during the rehabilitation process. Thus, an individual's compromised memory,
for instance, can affect the success of a rehabilitation program(12).

In this context,
an early diagnosis, jointly with the prognosis of the patient's cognitive potential,
can be very important to determining the best strategy to implement for these
patients, since interventions designed to recover from and/or compensate for
cognitive impairment can be initiated during the acute phase of CVA, which is
an important factor in treatment effectiveness(8).

However, even though
there is mention in the literature of cognitive impairment after a brain damage,
most studies addressing cognitive functioning after a CVA have focused on the
development of dementia(13). Data concerning the relationship between
the patients' neurological states at the time they begin physical therapy and
their cognitive performance is limited.

Therefore, therapeutic
procedures are limited since there are few studies guiding the implementation
of a therapeutic program focused on patients' cognitive needs.

This study reports
the neurological state and cognitive performance of post-CVA patients that are
part of a physical therapeutic rehabilitation program, investigated by a multi-disciplinary
team (Physical Therapists, Occupational therapists and speech and hearing therapists).

METHOD

This is a cross-sectional
analytical study. The population was composed of patients with CVA who received
physical therapy from the five largest public services in the city of Natal,
RN, Brazil (the physical therapy units at the Onofre Lopes University Hospital,
Potiguar University, Asa Norte Clinical Center, José Carlos Passos Clinical
Center, and Adult Rehabilitation Center) between May 2007 and May 2008.

The contingency
sample was composed of 45 individuals selected according to the following inclusion
criteria: (a) having a CVA diagnosis confirmed by complementary exam (CT or
MRI); (b) having been cared for by the physical therapy service in one of the
chosen institutions in the research period; (c) being 40 to 90 years old; (d)
time of CVA less than three months prior at the time of assessment; and (e)
CVA had to be unilateral and non-recurrent.

Exclusion criterion
was the presence of associated pathologies that could cause cognitive sequelae
beside those caused by CVA, such as Parkinson and Alzheimer's disease. Patients
with severe aphasia and visual impairments were also avoided.

Data collection
instrument

A physical therapy
form was used to collect general information about patients, such as identification,
clinical condition, history of current disease, pathological and family antecedents,
lifestyle, medication and physical assessment (palpation and inspection) according
to the model used by the Physical Therapy Service at the Onofre Lopes University
Hospital (HUOL-UFRN).

The Mini Mental
State Examination (MMSE) was used to evaluate the cognitive condition of patients.
This instrument identifies evidence of cognitive impairment in patients(14)
and is divided into seven dimensions including: time and spatial orientation,
immediate memory, attention and calculus, evocation, language and visual construction.
Its total score varies from 0 to 30. This instrument was validated for Brazil
and takes into account the age and educational level of the interviewed individuals(15).

The Stroke Scale
by the National Institute of Health (NIHSS), the validity and reliability of
which is well documented both in Brazilian and international literature, was
used to quantitatively assess the neurological state of patients(16-18).
This scale is composed of 11 items that include: level of consciousness, eye
movements, visual fields, facial palsy, motor function and limb ataxia, sensory,
language, dysarthria, and spatial neglect(18). In this scale, the
higher the patient's score, the more severe is his/her neurological state. Scores
below 5 at the time of admittance suggest mild clinical severity; scores between
6 and 13 indicates moderate severity; and scores equal to or greater than 14
indicate a more advanced level of clinical severity(16).

Data collection
procedures

The research project
was initially submitted to the Research Ethics Committee guiding research with
human subjects at the Federal University of Rio Grande do Norte (UFRN). After
its approval, in accordance with resolution 196/96 protocol No. 12/2007 CEP/UFRN,
the researchers were trained to collect data in order to standardize the procedures.
Before the application of the protocol, each participant was informed of the
study's objectives and limitations and signed a free and informed consent form
confirming their voluntary participation. The instruments were applied only
once at the beginning of the physical therapy.

The data obtained
were tabulated and statistically analyzed through SPSS version 13.0. According
to the Kolmogorov-Smirnov normality test and a level of significance fixed at
5%, a normal distribution of data was assumed in this study.

Descriptive statistics
(frequency, averages and standard deviation) are presented to characterize the
investigated sample. Inferential statistics was applied to the remaining analyses.
To verify the existence of significant differences between the cognitive averages
concerning education, the Student t test was initially used in independent
samples and Pearson's correlation test was applied
to check for the existence of a correlation between cognitive performance and
the neurological state of patients.

RESULTS

The studied sample
was characterized in terms of personal aspects (gender, marital status, age
and schooling) and clinical aspects (etiology of CVA, affected brain hemisphere,
manual motor dominance). The results indicated a sample of 45 predominantly
female (55.6%) and married patients (57.8%). The average age of the individuals
was 65.6 years old (±10.6). The majority had attended primary school (n=21,
46.6%), followed by illiterate individuals (n=14, 31.1%).

In relation to
clinical characteristics, the most prevalent CVA etiology was Ischemic CVA (86.7%)
and the right brain hemisphere was the most affected (60%). In relation to laterality,
86.7% of the patients were right-handed.

In relation to
the patients' neurological condition, the average score obtained by patients
in the NIHSS in relation to their clinical severity was 13.0 ± 4.8. In
relation to their cognitive performance, the average obtained in the MMSE by
illiterate patients was 15.92 ±3.75 and by educated patients was 19.32
±5.0. A statistically significant difference was found in the cognitive
averages of patients in relation to schooling (p value = 0.017) (Table
1).

Finally, when analyzing
the existence of a relationship between the patients' neurological state and
cognitive performance, we verified the presence of a negative and significant
relationship (r= -0.34 p-value =0.002), which shows that the greater the neurological
severity, the worse the cognitive performance of patients (Figure
1).

DISCUSSION

Current rehabilitation
programs directed to post-CVA patients neglect the cognitive dimension of these
patients, which seems to hinder the success of their treatment. Appropriate
treatment may favor recovery in patients who are cognitively compromised when
admitted into a rehabilitation unit in the initial phase of CVA(6).
With this in mind, this study was conducted to investigate, using a multi-disciplinary
team, the neurological state and cognitive performance of post-CVA patients
with up to three months of brain damage at the time they were admitted into
the public physical therapy services in the city of Natal, RN, Brazil.

The results revealed
a sample of patients with an average age of 65 years old, a fact consistent
with the literature that reveals a greater concentration of individuals older
than 60 years of age with cardiovascular diseases(1,4). Additionally,
the initial assessment showed a moderate neurological state (average of NIHSS
13 ± 4.8), which indicates the need to understand the cognitive level of
these patients to implement a more effective treatment.

Some authors report
that the final score obtained by patients in the NIHSS at the time of their
admittance into the therapy service can help plan the recovery of patients by
predicting the care required in the long term(16). According to these
authors, more than 80% of patients scoring less than 5 points at the time of
admittance are discharged quickly without major intercurrences. Those scoring
between 6 and 13, however, usually require a more elaborate rehabilitation program.
Finally, those scoring 14 or more, frequently require more intensive rehabilitation
care and for a more prolonged period(16).

The cognitive dimension
is evident in the case of patients with severe levels of neurological impairment
because the severity of CVA seems to be related to a tendency for individuals
to present cognitive dysfunction. Such a dimension stands out when one acknowledges
the need for cognitive integrity to experience therapeutic success.

The effect of the
patients' cognitive condition in the CVA rehabilitation process presents a different
context(10). It occurs because the effect of cognition on the rehabilitation
process is a matter of great controversy and has led the scientific community
to much debate(11-12). Researchers have reported that patients with
cognitive impairment can improve their functioning when attending a rehabilitation
program(10).

In this context,
various studies have tried to identify the relation between the success of rehabilitation
and the degree of cognitive impairment, leading researchers to suggest that
a cognitive assessment should be part of the rehabilitation process(10-12).
Studies with post-CVA patients have shown that individuals with some cognitive
deficit present unsatisfactory results in the rehabilitation process. This may
occur in patients with sensory or attention deficit, or compromised learning
and comprehension skills(11-12).

In agreement with
this rationale, some researchers suggest that an individual's cognitive state
can influence the results of treatment because the techniques used in this process
require certain cognitive skills, such as evocation and performance of instructions,
and these skills are generally compromised in these patients(10).

In this study,
the cognitive assessment of patients was performed using the MMSE. The results
indicated that the averages obtained by patients in this instrument were below
the cutoff points proposed for the Brazilian population in the MMSE validation(15),
both for educated and illiterate patients, suggesting this population presented
some level of cognitive impairment.

A study using the
MMSE and addressing the diagnosis of dementia in Brazil proposed cutoff points
of 23 and 24 for educated elderly individuals and 19 and 20 for illiterate individuals,
highlighting the influence of patients' educational level on their cognitive
performance(15). Such findings are corroborated by those obtained
in this study in which educated patients presented cognitive averages greater
than that of illiterate patients; the difference was statistically significant
(p value=0.017).

Finally, we investigated
whether the neurological state of patients at the time they were admitted into
the physical therapy service was related to their cognitive performance. A negative
and very significant relation was found, which was evidence that the more severe
the neurological state of patients, the worse was their cognitive performance.

Such a fact is
highly relevant for the implementation of a rehabilitation program. The cognitive-motor
influence is of considerable clinical importance, since the performance of exercises
requires simultaneous motor and cognitive skills(19). Therefore,
cognitive domains affected by neurological impairment should be identified so
that more coherent treatment planning is devised and, consequently, patients
achieve improved recovery from neurological and cognitive damage(19-20).

An early diagnosis
jointly with the prognosis of potential cognitive recovery can be very important
in the determination of better interventions to be implemented for these patients,
since interventions intended to recover from and/or compensate for cognitive
impairment could be initiated in the CVA acute phase, which is important for
treatment effectiveness(8).

CONCLUSION

According to the
findings of this study, we conclude that the level of neurological severity
found in the initial assessment of patients at the time they were admitted into
the physical therapy service was moderate and the cognitive performance was
below the Brazilian cutoff points. Additionally, the study indicated that these
two variables seem to be directly related, which shows the need to pay more
attention to the cognitive dimension involved at the beginning of the rehabilitation
process of these patients.

Despite the relevance
of the findings, this study presents a certain limitation since potential influences
of how extensive the damage was and the topography of damage on the cognitive
state of the studied patients were not considered. However, since the NIHSS
was applied and this instrument evaluated the severity of an individual's neurological
condition, we believe this limitation has little significance for this study.
Hence, we expect that its findings will contribute to future studies addressing
the cognitive level of post-CVA patients, aiming to develop therapeutic interventions
consistent with this clinical situation.